Critical Path Network

VA gets high marks for preventive, chronic care

Integrated medical record needed but not sufficient

A study published in the Dec. 21, 2004, Annals of Internal Medicine showed that patients enrolled in the Department of Veterans Affairs health system (VHA) were more likely than a national sample of similar patients in the general population to receive preventive care and chronic care recommended by established national guidelines.

The study compared 26 facilities in 12 VHA health care systems and 12 different communities; a total of 596 VHA patients and 992 patients identified through random-digit dialing; all who were involved were men older than 35.

The researchers measured quality over the period between 1997 and 2000, using RAND’s Quality Assessment Tools system to evaluate inpatient and outpatient care for 26 conditions.

The VHA scores were based on 294 of 348 indicators (there were no eligible patients for some indicators), and 330 indicators for patients on which to base national scores.

Included were such measures as aspirin for patients presenting with acute myocardial infarction, diet and exercise counseling for diabetes, and screening for colorectal cancer.

Here are the highlights of the findings:

  • Patients from the VHA scored significantly higher for adjusted overall quality (67% vs. 51%).
  • Patients from the VHA scored higher than the national sample for both chronic care (72% vs. 59%) and preventive care (64% vs. 44%).
  • Patients from the VHA did not score higher than the national sample for acute care (53% vs. 55%).

"This same team a year and a half ago published a paper in the New England Journal of Medicine1 that looked at quality in this country as a whole and basically concluded it was a flip of the coin as to whether or not you got good care," notes Steven M. Asch, MD, MPH, of the West Los Angeles Veterans Affairs Medical Center and lead author of the Annals article.

"This spurred us to think about what sorts of systems do a better job, and if so, why. The VA came to top of mind because it has put together an information superhighway, measures performance, and holds providers accountable, so we embarked upon a study to see if indeed it was doing a better job, and we found that they are. In general, VA patients get the care they need two-thirds of the time," he explains.

What’s the take-home message?

There are a number of significant take-home messages in the study, but according to Asch, one point stands out when it comes to quality improvement.

"For quality managers especially, what’s most significant is that what gets measured gets done," he asserts.

In other words, the VHA advantage was most prominent in processes targeted by VHA performance measurement (66% vs. 43%), and least prominent in areas unrelated to VHA performance measurement (55% vs. 50%).

According to the authors, "Differences were greatest in areas where the VHA has established performance measures and actively monitors performance."2

Just as significant, Asch explains, is that there appears to be what he calls a spillover effect for improvement.

"So, for instance, if you look at a particular condition, the VA does best in things it is measuring; it does about the same in things that it does not measure and has no relationship [to the condition]; but in things that are kind of alike but not exact, it still has an advantage," he notes.

"So, for example, if the VA is tracking blood pressure control, it may not be tracking whether a patient with high blood pressure gets his creatinine measured," Asch stresses.

"But these patients at the VA do get their creatinine measured more often [than the nationwide average], even though it is not one of their performance measures. In other words, the VA also has an advantage in things that are kind of like the things that are being tracked," he continues.

VHA requires accountability

One of the factors that distinguishes the VHA, and is thought to be a contributing factor in the results of the study, is that the VHA, the largest health care delivery system in the United States, began in the early 1990s to institute an electronic medical record system, as well as an approach to quality measurement that assigns accountability to regional managers for processes in both preventive care and chronic condition management.

"The integrated medical record plays an enormous role," says Asch, but he adds that he considers it "necessary but not sufficient."

In other words, he explains, "Lot of folks think that if they just instituted electronic medical access they’d improve, but then they don’t track performance or hold people accountable."

The system used by the VA, called CPRS (computerized patient record system), is quite interactive. "As a provider, it helps me remember things," explains Asch, noting that it is a reminding software.

"When I’m sitting at my desk [and bring up a patient’s record], it will say, How about giving him a flu shot?’ Or if a patient is diabetic, it may note he has not had a hemoglobin A1C in the last four months, and ask if I want to order one. At the VA, there is a terminal in every examining room," he notes.

"You can view your X-rays on the screen, or see the results of your colonoscopy; there is no more paper," Asch explains. "The universality is another thing that distinguishes [the VA] from other systems; everyone knows how to use it."

The authors argue that "the implications of these data are important to our understanding of quality management.

"The VHA is the largest health care system to have implemented an electronic medical record, routine performance monitoring, and other quality-related system changes, and we found that the VHA had substantially better quality of care than a national sample," they note.

"Our finding that performance and performance measurement are strongly related suggests that the measurement efforts are indeed contributing to the observed differences," they write.

"Performance measurement alone seems unlikely to account for all the differences; the VHA scored better even on HEDIS measures widely applied in managed care settings (but not in other settings) outside the VHA."2

What the VA has done is certainly replicable in other large health care systems, Asch notes, although it is extremely expensive. "But can we afford not to do it?" he poses. "It’s disturbing to me and most providers — and many patients — that we are not getting what we need as often as we need to. If it requires investment to do so, we should do it."

Asch concludes with this thought: "I don’t want to leave the impression that information technology is the be-all and end-all of performance improvement; embracing technology all by itself is not enough," he says. "You also have to track performance; tracking performance is the key to improving care."


1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348:2,635-2,645.

2. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004; 141(12):938-945.